When a client in labor has spontaneous rupture of membranes and a cervix dilated to 1 cm, what should the nurse do first?

In this scenario where a client in labor experiences spontaneous rupture of membranes (also known as breaking of the waters) and the cervix is dilated to just 1 cm, the most appropriate first action for the nurse is to apply the external fetal heart rate monitor.

The rationale for this is centered on the importance of monitoring the fetal heart rate following the rupture of membranes. Once the membranes have ruptured, there is an increased risk of infection and complications such as cord prolapse. Continuous monitoring of the fetal heart rate is critical to assess the baby's well-being and to promptly identify any signs of distress.

Taking this step immediately ensures that any potential issues with the fetus can be detected early, allowing for timely interventions that can help safeguard both the mother and the baby. Monitoring the fetal heart rate provides vital data to guide further management and inform the healthcare team.

The other actions are significant, but they are not as immediate or pressing as establishing fetal monitoring at this stage. For instance, performing a vaginal examination might be necessary later to assess the progression of labor but could potentially introduce infection if done hastily after the membranes have ruptured. Notifying the provider is also important, but it typically follows the assessment of fetal status. Encouraging the client to